Objective: A retrospective analysis of all patients with cancer of the cervix attending regional cancer center of Indira Gandhi Institute of Medical Sciences, Patna, from June 2015 to June 2017. The aim of this study was to know patient demographics, histology, age, stage and status of presentation, compliance with treatment and follow-up. Materials and Methods: Five hundred and eighteen consecutively registered patients with cancer of the cervix were included in the study. Results: The prevalence of cervical cancer among gynecological malignancy was 52%. It is the second most common cancer after breast cancer at our center. Patients hailed from the various districts of Bihar (89%), India, and from Nepal (10.61%). The majority (>50%) were aged 40–59 years. Stage information was available for 71.81% of the patients, of which Stage I comprised 12.36%, Stage II, 35.21%; Stage III, 50%; and Stage IV, 2.41%. Squamous cell carcinoma was the most common reported histopathology (~90%). A significant proportion of the women defaulted after registration, or after undergoing investigations (17%). Of the 68% cases planned for treatment, 50% initiated it, but only 38% completed it, About 11% of cases underwent Wertheim's hysterectomy and rest of patients were treated by radiotherapy with or without chemotherapy. Conclusion: The incidence of cervical cancer is still unacceptably high at our center. Organized cervical cancer screening needs to be adopted for early diagnosis.

Cervical cancer is the fourth most common cancer among women worldwide and the seventh overall. Of an estimated 528,000 new cases in 2012, approximately 85% occurred in less developed countries, of which one fifth was diagnosed in India.[1] There were 266,000 deaths from cervical cancer in 2012, accounting for 7.5% of all female cancer deaths. Approximately 87% of the worldwide mortality for cervical cancer occurs in less developed countries.[2] Cervical cancer data in India are mainly derived from the population-based cancer registries (PBCRs) and hospital-based cancer registries (HBCRs). PBCR demographics[3] reveal that the incidence of cervical cancer is 30%. In the Barshi (rural and expanded) registry, cervix is the leading cancer, whereas in urban registries of Delhi, Bhopal, and Chennai, it is 14%–15%, whereas breast cancer is the most common. Data from the HBCRs area are little different. Cervical cancer remains the leading cause in Bangalore (27.5%), Chennai (28.0%), and Dibrugarh (14.4%), while it is the second most common in Mumbai (15.5%) and Thiruvananthapuram (11.0%).[4]

According to 2013, 70% of the Indian population lived in the rural area of the country.[5] The north-eastern districts of Tamil Nadu and Pondicherry having a high proportion of the rural population had reported a very high incidence of cervical cancer.[6] Ambilikkai Cancer Registry has reported the second highest incidence of cervical cancer in the world.[7]

The preinvasive stage of cervical cancer lasts for a long period, and only a small proportion of cervical intraepithelial neoplasia (CIN) progresses to an invasive lesion. The appropriate management of CIN can prevent invasive cervical cancer.[8] Thus, the detection of in situ cases or early stages of cancer remains key to decreasing cervical cancer mortality. In a recently reported trial by the Tata Memorial Hospital, Mumbai, performed on the rural population close to Mumbai, visual inspection with 5% acetic acid reduced cervical cancer mortality by 31 %. The incidence of invasive cervical cancer after 12 years reduced in the screened women.[9]

The risk of developing cervical cancer has been associated with a number of socioepidemiological factors such as age, parity, religion, socioeconomic status, educational level, and sexual behaviors.[10] Current cervical risk scoring systems are based on such sociodemographic variables and are often helpful in targeting the screening population. Even in the industrialized countries, the emphasis is now on precise targeting of high-risk groups to improve the efficiency of cervical cancer screening programs and conserve resources. Most cases are present in the advanced stages of the disease.

The present study was carried out in the Department of Gynaecological Oncology of Regional Cancer Centre of Indira Gandhi Institute of Medical Science, Patna, India. This is a retrospective analysis of patients of cervical cancer treated at regional cancer center from June 2015 to June 2017.

Patient's records were obtained and details of clinical history, complete clinical examination, and hematological, biochemical, and radiological investigation reports before the actual treatment plan and during treatment were recorded and analyzed. Most patients attended gynecological OPD for cervical biopsy, and few patients came with histopathology reports done outside. After diagnosis of invasive cervical cancer, all of the cases had been reexamined and staged according to International Federation of Gynecologists and Oncologists (FIGO) staging system.

The treatment policy depended on the FIGO stage and status of the first presentation of the patient's early disease (Stage up to IIA) admitted in gynecological oncology for surgery and advanced disease (Stage beyond IIA) sent to radiotherapy department for further treatment. Some patients directly visited to radiotherapy department referred from different departments of institute. A review of the histopathological diagnosis was obtained from the Department of Pathology in some cases.

The Chi-square test was used to test for statistical significance and P ≤ 0.05 was taken as being statistically significant. The results were analyzed by using Epi Info Version 6.00 by CDC.

» Results

A total of 1726 new cases of female genital tract and breast malignancy was registered under regional cancer center of our institute from June 2015 to June 2017. Out of which, 555 new cases were carcinoma of the cervix and 705 were breast cancer. The prevalence of cervical cancer among gynecological malignancy was 52%. After including breast cancer cases, the prevalence of breast cancer and cervical cancer were 40.84% and 30.01%, respectively.

Most of the women visited from various districts of the Bihar and some patients from adjacent area of Nepal. Majority of the patients, i.e. 441 (85.13%) were of the poor socioeconomic strata of the society with 99% being married. These values were statistically (P ≤ 0.05) significant. The prevalence of the disease increased proportionately with parity and grand multiparous women accounting 67.18% of the cases. Only 2.24% of the cases were nulliparous. The parity differentials were also statistically significant, P = 0.003 [Table 1].

The patient's ages ranged from 12 to 75 years with a mean of 51.17 ± 3.6 years. The majority of women were middle aged, i.e., in the 4th and 5th decade of their lives, although a sizeable population was young (<40 years) [Table 2]. Mode of presentation was described in [Table 3].

Stage information was not available for 28.18% (n = 146) of the patients [Table 4]. These cases had done surgery at other centers and presented as vault mass with bleeding per vaginum at our center. The treatment record details were either unavailable or the patient had not been staged before therapeutic intervention. The majority of the remaining, i.e., 72% presented with advanced-stage disease, majority of them were Stage III.

A treatment plan could not be generated for 17% of the women as they had defaulted after registration or after undergoing investigations. Sixty-eight percent of the women reporting at the hospital were new cases, having received no prior treatment. Only 11% (57/518) cases had undergone Wertheim's hysterectomy. Out of 567, 12 cases had also received postsurgery radiotherapy. Approximately 42% had undergone primary radiotherapy [Table 6].

Table 6: Plan details according to stage and status at initial presentation

The dose of external beam radiation therapy (EBRT) was 50 Gy in 25 fractions at 2 Gy per fraction, completed over 4½ weeks, followed by an intracavitary radiation therapy (ICRT). Postoperative patients received the same EBRT dose followed by ICRT. Since ICRT facilities were not available at our center; so, patients were referred to other center for this. The chemotherapy schedule used was a three-drug regimen of paclitaxel, carboplatin, and 5-FU. Carboplatin and 5-FU were given at a dose of 1.5 and 500 mg/m2 on day 1 and paclitaxel 80 mg/m2 on day 2. A total of 197 patients completed the treatment and 162 patients came for follow-up [Table 7].

Cervical cancer accounted for 52% (n = 518) of gynecological and 30% after including breast cancer patients. This is the second most common malignancy after breast cancer. The global trends reveal that African countries such as Malawi (75.9), Mozambique (65.0), Zambia (58), Zimbabwe (56), and central African countries are high-risk regions with the age-standardized rates of over 30 per 100,000 across 10 age groups.[12] Countries with low rates include Australia and New Zealand (5.5) and West Asia (4.4). Cervical cancer is the leading female genital cancer in our environment. This high prevalence rate might be a reflection of the lack of an organized cervical cancer screening program in our environment as in the case in the industrialized nations of the West. This is also the observation of other researchers.[13]

The mean age of the patients was 51 years. The majority of women were in the fourth, fifth, and sixth decade of life. Approximately 15% were young having age <40 years. Demographics from HBCRs show that 30%–40% of cases lie in the range of 40–60 years across all registries. It was revealed from the study of rural India by Thulaseedharan et al. that the maximum number of cervical cancers are diagnosed in the fourth and fifth decade of life.[14] According to the Surveillance, Epidemiology, and End Results Program statistics, most women with cervical cancer are identified before the age of 50. Older women remain at risk, and more than 20% of new cases are diagnosed in women aged 65 years and older.[15] By contrast, cervical cancer in the UK is common in women aged 15–34 years and is accountable for 16% of all cancer that is diagnosed in this age group. It is primarily a disease of the young with peak age of diagnosis is 25–29 years.[16]

By contrast, cervical cancer in the UK is common in women aged 15–34 years and is accountable for 16% of all cancer that is diagnosed in this age group. It is primarily a disease of the young with peak age of diagnosis is 25–29 years.[16] SCC was the most frequent histopathology reported (91%), of which Grade I comprised 38% of all cases. Adenocarcinoma was reported in 1.73% of cases. In India, 85%–90% of cervical cancer cases are SCC, and human papillomavirus (HPV) 16 is the most prevalent type among them, compared to other parts of the world where the proportion of HPV16 is much lower. In India, the prevalence of HPV16 alone in cervical cancer is 70%–90%, while the occurrence of HPV18 varies from 3% to 20%. Adenocarcinoma accounts for more than 25% of all cervical cancer cases in Western countries, and HPV18 is reported to be prevalent in more than 86% cases. In contrast, in India, only 10%–15% of cervical cancer cases are adenocarcinoma, and HPV16 is the most prevalent type although it is less frequent than that found in SCC, i.e., 42% versus 70%–90%.[17]

A majority (89%) presented with advanced stage disease with Stage IIB and IIIB, accounting for 23.16% and 35.13% of all cases, respectively. This is a common feature of cervical cancer in the less developed countries of the world.[13] The impact of socioeconomic factors pertaining to the stage of cervical cancer patients at diagnosis was analyzed in the study from South India.[18] Those widowed or divorced, or having a lower level of education, reported to the hospital late. They enumerated that such a trend exists because there is no support from families. Those with little to no education do not understand the implications of the disease process. Most of the cases presented as new cases, i.e., they had not received any prior treatment.

Approximately 28.18% of the patients were registered after having undergone surgery outside our center. Of these, a significant proportion had residual or recurrent disease. This is because most of these patients had received treatment at the hands of surgeons with inadequate skills or knowledge of oncology.

A treatment plan was generated for 68% of the total registered patients, but only 38% completed it. These figures reveal the lack of awareness and compliance with treatment in the rural population of our country. HBCRs also reveal a similar picture. Fifty percent of patients did not receive any treatment according to the Chennai registry, 47% according to the Mumbai registry, and 37% according to the Bangalore registry, which is interesting to note since all of these registries have a more urban population registration than other parts of the country. A retrospective analysis of cancer cervix patients carried out in Kolkata by Mandal and Roy showed a similar picture of almost 40% of patients not undergoing any treatment at all.

» Conclusion

The incidence of invasive cancer of the cervix is still unacceptably high at our center with the prevalence of 54% among gynecological malignancy and the second most common cancer in women after breast cancer. The risk factors associated with the disease were age, multiparty, and poor socioeconomic status. The majority of the patients hailed from remote villages. The prevalence of adenocarcinoma is less. A large proportion of the patients presented in advanced stages of the disease and with residual mass at vault due to incomplete surgery.

There is a need to start organized cervical screening program not only at tertiary center but also at primary health centers. Departments and doctors dedicated to gynecological malignancy should be established, promoted, and developed to avoid incomplete surgery and recurrence.

National Centre for Disease Informatics and Research, National Cancer Registry Programme, Indian Council of Medical Research. Three-Year Report of Hospital Based Cancer Registries 2008-2010. ICMR; 2013.